04040136 (4) CITY OF CUPEWFINO
BUILDING DIVISION PFRMIT 9C0NTRXGT10R4NFORMATION
BUILDING ADDRESS: ULTRAS I GNS PERMIT Nc0 4 04 013 6
21000 STEVENS CREEK RD
Its NAME: PERMIT ISSUE DATE
PANDA EXPRESS 5458 COMPLEX 2004
70 NE: SANITARY NO. CONTROL NO.
(858) 569-6716
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
tlLDG ELF.Ci PLUMB MECH
0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION
w g1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Sectio 1)of Division 3ordte Bu' d Pumusions Cade.and my license is
��a LBuI.eC_ erten. INTERIOR SIGN C�0 L���
_ LiccnuC s �f Lic.
g=0 Da af�g.3 Conlraclor
e ARCHITECTS D AT]ON 2
L I understand my plana shall he used as public records APR 2 2004
Dau
T O Licensed Pnafcssional
OWNER-BUILDER DECLARATION ����®�ra�A
Wq 1 naso ,Item on I ons exempt from the Contractor's o License Law for the I�lpp®®V911G
p o which ire reason,(Section]11]15,Business and improve,
demob Code:Any city or musty
k$� which rcyuires a Permit to combos.alter,impmvc,Jemnlish,or repair any structure
yZY prions its issuance,also requires lheapplicant fimauch permiuu file axignedmilemenl
pp < that he isliccnudpursuanunthe previsions ofthe Contractor aLicenuLaw(Chapter 9 Sq. Ft. Floor Area Valuation
Y�m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y BOB he is exempt therefrom and the basis rot the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pench subjects the applicant o a civil penalty of 35 �er00 Occupancy Type
not more Nan Eve hundred dollars(11001,
P Y YP
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Ct mnctor's Live.Law does nut apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for rte.If,
however,the building or improvement is said within arc year of completion,the owner
builder will hove Ne burden of proving door he did not build or broom for purpose of
sale].
❑I,as owner of the pmpony,am exclusively contracting with licensed contractors to
cunstmet the project(Sec.7044,Business and Professions Code:)The Comraelor's Li.
cense law does not apply to an owner of property who Mei Ids or improves thereon,and
who contracts for such pmjecr with a coutrsemr(s)licensed pursuant o has Cantrmoh
License Law,
❑I am exempt untler Sec. ,B&PC for this resson
Dat
WORKER'S COMPENSATION DECLARATION
1 hereby opine under penalty of perjury one of the following declarations:
El I have and will maintain a Cenifivam of Consent to set binsum for Worker's Compcm
cation,as provided for by Section 37W of Ne labor Code,for the perfamunce of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a required by Section
37M of the labor Code,for Ne performance of the work for which this Permit is issued.
My Wonmc.C�om rayl nn lnsunnm nrticr end Policy b'cr�ar�e:''��
CERTIFIC ON WORKERS'
COMPENSATION INSURANCE ,
(This section need nm he completed lithe ,.if is foronc hundmd dollars(5100)
,it Ices.)
1 ecnify that in Ne performance of the work for which this Permit is issued.I shall not
employ any Nunn in any manner»as to became subject to the Wofkerf Compensallon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after ortng this Ceniftcatc of Exemption,you should
become subject 10 the Worker's Cam pcnsation provisions of the Labor Code,you must
.J z forthwith comply with such provisions or this Permit shall be deemed revoked.
„Z,aO CON STRUCG ON LENDING AGENCY
Ea I hereby affirm Nal there is a construction lending agency l or the Performance of
Ri
0e work far which this permit is issued(Sec.309].Civ.C.)
W Lender's Name
=z Lender's Address
U O 1 ecnify that I have read this application and sure that the above numeration is
W I"' correct.l agree to comply with of city and county ordinances and arts laws relating to
C U abowng construction.On.and for
authon p representatives Of this City menter upon re a,
W ahovc(We)
property(in inspection purposes. /
0. (Wc)agree to save,indemnify and keep harmless the City of Cupentno agatnsl
rq liabilitics,judgmenta,costs and expenses which may in anyway aecmc against said City
J in consequence of the granting of this permit.
^'
APPLICAW,,XNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEULATIONS.
-�p'� Re-roofs
5�1aw of ApplicanUC mneme aim
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building omupam stem or handle havallous material
as defined by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safety
coca.smtmn zss3z(a)9
❑Yes All roofs shall be inspected prior to any roofing material being installed.
•ANu
Will the applicant or r/ulum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hvardnus air coutaminanu as defined by the Bay Arca Air Quality Managcmem all new materials for inspection.
Diwic4
1-1 Yes Y
I have read Ne bnallous materials mquimmems under Chapter 6.95 of the Caffnr,
niaHcalth Safely Cwlc,Scions 25505.25533 and 25534.1 understand doth if Ne Isildtng
dues not Wendy hove a¢nam,doth it is my rcspmsibiliry,to notify the occupant of the
myuire nu whichmuslImctpriur issuanccofeCcNIf of0t,romy. _ Signature of Applicant Date
t�
Owner or authorircd gcm All roof coverings to be Class "B"or better
aDate